Osteoporosis - is a systemic skeletal  disease characterized by low bone mass and increased  bone fragility resulting in a high risk of low-impact fractures. 

 

A pathological fracture (low energy fracture) - is a fracture caused by insignificant (low energy) impact, whereby the normal bone tissue would have remained unaffected. There are several reasons responsible for this condition, including destructive processes inside the bone tissue  (tumors) and osteoporosis. 

 

The most common fractures caused by osteoporosis are  a vertebral compression fracture, a cervical hip fracture,  forearm and upper arm fractures [1].

Loss of  vertebrae height due to compression fractures.

The causes of osteoporosis can be classified into primary and secondary.  Primary type includes  postmenopausal, senile (elderly) and idiopathic juvenile osteoporosis. Secondary type is  caused by various endocrine, drug, metabolic and toxic related reasons.

 

About 85% of all cases are related to primary osteoporosis, predominantly to postmenopausal [1]. The causes of secondary osteoporosis are:

 

  • long-term oral glucocorticoids therapy;

  • hypogonadism (diminishing or  suspension of the gonads functional activity in both men and women);

  • thyrotoxicosis and long-term high dose thyroid hormone therapy;

  • chronic kidney disease;

  • rheumatoid arthritis and Bekhterev's disease (Ankylosing spondylitis);

  • gastrointestinal tract dysfunction causing impaired calcium absorption;

  • various blood disorders;

  • genetic disorders;

and many other reasons.

 

DXA (dual-energy xray absorptiometry) is generally used to diagnose osteoporosis. It is performed on the lumbar spine and the bone of the upper thigh. The technique allows to assess a loss of bone material both at  the early-stage (osteopenia) and  late-stage (osteoporosis). The results are interpreted using the World Health Organisation criteria. X-ray and laboratory tests are also used to diagnose osteoporosis. It is the doctor who distinguish the disease among others of similar nature, makes a final diagnosis and develops treatment plan.

 

There are no clinical symptoms of osteoporosis apart of the fractures that have already happened. Therefore, for the early prevention and treatment of osteoporosis   it is important to know and understand the risk factors. These include: systemic  glucocorticoids therapy  continuing for more than 3 months, smoking, excessive drinking, age more than 65 years old, female gender, history of fractures, genetics, etc. It is worth to mention another important factor as low BMI (Body Mass Index). BMI less than 20 and/or body weight less than 57kg. increase the risks of osteoporosis [2]. 

Loss of body weight more than 10% at the age more than 25 years old is also a significant factor.

 

One more important risk factor is a lack of physical activity. There is a relation between the physical activity in young age and a greater  bone tissue density.  The absence of regular physical activity can lead to loss in bone mass. A number of meta-analyses have shown that a bone mineral density is 25% higher in sportsmen rather  than people doing regular physical activity, and the latter is 30% higher than people with little physical activity [4]. Bone mineral density in young individuals is associated with physical activity, regardless of age and vitamin D level [19]. Raloxifene combined with aerobic exercises  therapy  is more effective in improving bone density in  patients with  senile osteoporosis, rather than isolated raloxifene therapy. The outcome is based on  randomized controlled trials including 70 elderly patients [20]. Two sessions per week is the minimum amount of physical exercises affecting bone mineral density during menopause.

 

However, the optimal type of physical exercises improving  bone mineral density is still unclear. 

 

In modern scientific literature, there are three types of physical exercises potentially effective against osteoporosis:

  • bodyweight exercises;

  • resistance exercises;

  • balance exercises.

 

Dynamic bodyweight exercises (walking, game-based exercises, etc.) are performed from standing position and involve  skeleton parts mostly affected by osteoporosis - spine and and upper thighs. These exercises can increase bone mineral density up to 1% per year [5]. In relation to osteoporosis, bodyweight exercises are more effective rather than resistance exercises. It is  important to mention that long distance running is not recommended, while exercises with both feet lifted off the ground simultaneously  (e.g. jumping) should be completely avoided [6]. Walking compared to regular physical activity  is  found to be more efficient to improve bone mineral density of spine and upper thighs [7]. Walking sessions have to be regular, at least 4 hours per week, total weekly recommended  distance is 12km. divided into 3-4 sessions.

 

Strengthening exercises with resistance (swimming, machine workouts, exercises with elastic bands) help to increase  bone mineral density of the spine and reduce its loss in the hips [8]. There is some data on the effects of  the upper limbs  strengthening exercises to increase hip bone mineral density, apparently due to their systemic effect [9]. Resistance exercises compared to walking  reduce bone resorption markers in a greater degree in individuals with osteoporosis. 

 

The third aspect of physical activity described in clinical guidelines  is coordination and balance exercises. Having no effect on  bone mineral density, it is suggested that they help to reduce the risks of falls [10]. Fall risk level plays a  significant role in the treatment of osteoporosis as it  determines the risk of pathologic fractures. The risk of falls may increase due to many reasons: chronic cerebral circulation disorders and other neurological diseases,  loss of  coordination and impaired vision caused by drug therapy and many others.  Fall-risk evaluation can be performed with the help of Timed Up and Go test. It uses the time that a person takes to rise from a chair, walk three meters, turn around, walk back to the chair, and sit down. The scores of more than 10 seconds indicates a high risk of falls [1].

 

Hatha yoga includes all the described types of physical exercises, that is why it can be used as an effective system of exercises  to treat osteoporosis. A 10 years  study involving 774 volunteers has shown  that regular yoga practice increases bone mineral density [11]. Another research suggests  that weight-bearing hatha yoga training  three times per week  during three months reduces the bone reabsorption speed in postmenopausal women with osteopenia or osteoporosis [14].  One more experimental study shows  a significant change in DXA results from -2.69 ± 0.17 before the experiment to  -2.55 ± 0.25 afterwards [15]. The study involved 30 women with postmenopausal osteoporosis aged between 45-62 years old who had been attending yoga classes during 6 months. The exercise program included both weigh-bearing and non weight bearing asanas, surya namaskar and pranayama.

 

However,  it is still unclear which asanas lower the risks  and bring greater benefit for the individuals with low mineral density. The main databases  review (PubMed, Medline and Cochrane) for the period of time from 1996 to 2011 indicates that  spinal flexion movements may increase the risk of vertebrae compression fractures. However, combinations of gentle extension and flexion movements may have positive impact. The optimum  type of physical activity  for individuals with osteoporosis are: moderate intensity weight bearing exercises as well as  exercises for strengthening the spine and  improving the posture, balance and life quality. The authors of the review emphasize that yoga therapists should not use the same approach with all the patients.  Further studies are needed to understand fully which asanas are the most suitable for patients with osteoporosis.

 

From one point of view, resistance and balance  exercises are recommended for the elderly people with osteoporosis, from another point of view high amplitude extension, flexion and rotation movements as well as extreme outer and inner hip rotations are contraindicated. In this case, exercises  performed from standing or lying positions in  average amplitude degree are preferred [16].

 

Moreover, wrong kind of exercises may lead to negative consequences. Sinki M. mentions about 3 cases of vertebrae  compression fractures in patients with osteopenia as a result of yoga spinal flexion positions. All the patients had never had fractures before, were in good health and pain-free without any symptoms of osteopenia.

 

Therefore, the practice of hatha yoga with diagnosed osteoporosis will be focused on:

 

  • Standing asanas (where the body weight is distributed on the spine and hips). According to scientific research, regular practice of the main standing postures (virabhadrasana, trikonasana, parshvakonasana, etc.) will help to restore mineral bone density. These asanas can be performed in both static and dynamic mode. A separate issue is one leg balance postures (virabhadrasana-3, ardha chandrasana, vrikshasana). They increase the axial loading on the femur bone and especially the femur neck which is the most common place where the fracture happens. There are grounds to believe that patients with severe osteoporosis (T score on DXA less than -2,5 with history of a fracture) should eliminate standing balance postures from their practice;

  • Asanas  for strengthening erector spinae muscles (sarpasana, niralamba bhujangasana,  shalabhasana variations,  marjariasana cycle)  and major muscle groups in static and dynamic modes, performed in average amplitude degree (adapted variations of surya namaskar);

  • Techniques improving balance and coordination. Dynamic exercises for  the feet in a standing pose, walking on the bricks, difficult coordination tasks.

 

Patients with diagnosed osteoporosis (especially the severe case)  should eliminate from the practice the following:

 

  • One leg balance asanas (virabhadrasana-3, ardha chandrasana, vrikshasana, etc.);

  • Extreme positions of the spine: intense flexion postures (paschimottanasana, etc., jalandhara bandha and all asanas where it can be done), intense  extension postures (chakrasana and other deep backward bends), twists where the arms act as a lever (ardha matsyendrasana etc.);

  • Extreme positions of hip joints (samakonasana, hanumanasana);

  • Deep variations of badhakonasana with the application of external force;

  • Jumps, jumps back and through;

  • Axial load on cervical vertebrae (sirsasana);

  • Patients with severe cases of osteoporosis should avoid axial load on one hand  (vasishthasana), and possibly on both hands (adho mukha vriksasana hand stand).

 

The more sever the degree of osteoporosis, the more strictly these precautions have to be followed. The World Health Organisation uses a criteria to determine  severe cases of osteoporosis as following: T score on DXA less than -2,5 with history of a fracture. Nevertheless, less serious cases of osteoporosis also require a careful approach to  developing rehabilitation program, taking into consideration above contra-indications.

 

References

 

  1. О.М. Лесняк, Н.В. Торопцова, Федеральные клинические рекомендации по диагностике и лечению остеопороза, 2014 г.

  2. University of Michigan Health System. Guidelines for Clinical Care: Osteoporosis: Prevention and Treatment. — July, 2005 

  3. Brown J.P., Josse R.G. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada // CMAJ. — 2002. — 167 (10 suppl). — P. S1–S34. 

  4. Institute for Clinical Systems Improvement (ICSI) Health Care Guideline: Diagnosis and Treatment of Osteoporosis, 5th edition, July 2006. 

  5. Wolff I., van Croonenborg J., Kemper H.C.G. et al. The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women // Osteoporosis Int. — 1999. — No 9. — P.1–12. 

  6. Scottish Intercollegiate Guidelines Network (SIGN) # 71: Management of osteoporosis: a national clinical guideline. — June 2003. — www.sign.ac.uk. 

  7. Bonaiuti D., Shea B., Iovine R. et al. «Exercise for preventing and treating osteoporosis in postmenopausal women»: Cochrane Database of Systematic Reviews and the Cochrane Musculoskeletal Injuries Group trials register (up- date 27.02.2002). 

  8. Stengel S.V., Kemmler W., Pintag R. Power training is more effective than strength training for maintaining bone mineral density in postmenopausal women // J. Appl. Physiol. — 2005 Jul. — No 99(1). — P. 181–188. 

  9. Judge J.O., Kleppinger A., Kenny A. Home-based resistance training improves femoral bone mineral density in women on hormone therapy // Oste- oporos Int. — 2005 Sep. — No 16(9). — P. 1096–1108. 

  10. Lee M.S., Pittler M.H., Shin B.C., Ernst E. Tai chi for osteoporosis: a systematic review // Osteoporos Int. — 2008 Feb. — No 19(2). — P. 139–146. 

  11. Lu YH, Rosner B, Chang G, Fishman LM. Twelve-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss. Top Geriatr Rehabil. 2016 Apr;32(2):81-87. Epub 2015 Nov 5.

  12. Smith EN, Boser A. Yoga, vertebral fractures, and osteoporosis: research and recommendations. Int J Yoga Therap. 2013;23(1):17-23.

  13. Gombos GC, Bajsz V, Pék E, Schmidt B, Sió E, Molics B, Betlehem J. Direct effects of physical training on markers of bone metabolism and serum sclerostin concentrations in older adults with low bone mass. BMC Musculoskelet Disord. 2016 Jun 8;17:254. doi: 10.1186/s12891-016-1109-5.

  14. Phoosuwan M, Kritpet T, Yuktanandana P. The effects of weight bearing yoga training on the bone resorption markers of the postmenopausal women. J Med Assoc Thai. 2009 Sep;92 Suppl5:S102-8.

  15. Motorwala ZS, Kolke S, Panchal PY, Bedekar NS, Sancheti PK, Shyam A. Effects of Yogasanas on osteoporosis in postmenopausal women. Int J Yoga. 2016 Jan-Jun;9(1):44-8. doi: 10.4103/0973-6131.171717.

  16. McArthur C, Laprade J, Giangregorio LM. Suggestions for Adapting Yoga to the Needs of Older Adults with Osteoporosis. J Altern Complement Med. 2016 Mar;22(3):223-6. doi: 10.1089/acm.2014.0397. Epub 2016 Feb 19.

  17. Sinaki M. Yoga spinal flexion positions and vertebral compression fracture in osteopenia or osteoporosis of spine: case series. Pain Pract. 2013 Jan;13(1):68-75. doi: 10.1111/j.1533-2500.2012.00545.x. Epub 2012 Mar 26.

  18. Kemmler W, von Stengel S, Kohl M. Exercise frequency and bone mineral density development in exercising postmenopausal osteopenic women. Is there a critical dose of exercise for affecting bone? Results of the Erlangen Fitness and Osteoporosis Prevention Study. 2016 Aug;89:1-6. doi: 10.1016/j.bone.2016.04.019. Epub 2016 Apr 21.

  19. Tønnesen R, Schwarz P, Hovind PH, Jensen LT. Physical exercise associated with improved BMD independently of sex and vitamin D levels in young adults. Eur J Appl Physiol. 2016 Jul;116(7):1297-304. doi: 10.1007/s00421-016-3383-1. Epub 2016 May 5.

  20. Zhao C, Hou H, Chen Y, Lv K. Effect of aerobic exercise and raloxifene combination therapy on senile osteoporosis. J Phys Ther Sci. 2016 Jun;28(6):1791-4. doi: 10.1589/jpts.28.1791. Epub 2016 Jun 28.

 

Artem Frolov

Original article is here

How yoga can help to slow down osteoporosis